Deliverable D7.2 Report on SIG4 Technical infrastructure

ICT PSP – Empowering patients and supporting widespread deployment of telemedicineservices

MOMENTUM

European Momentum for Mainstreaming Telemedicine Deployment in Daily Practice(Grant Agreement No 297320)

Deliverable D7.2

Report on SIG 4 –"Technical infrastructure and market relations"

“Technical infrastructure and market relations report for the blueprintvalidated by ‘doers’ and stakeholders”

Version 10

Work Package: WP7 SIG on technical infrastructure and market relations

Version & Date: V10 / 15-09-2014

Deliverable type: Report

Distribution Status: Public

Authors: Tino Martí

Reviewed by: Ellen Christiansen, Gérard Comyn, Rachelle Kaye, Marc Lange, Bruna Miralpeix,Peeter Ross, Diane Whitehouse (including reviews of case descriptions)

Approved by: Marc Lange, Michael Strübin

Filename: D7 2_MOMENTUM_SIG1_v10

AbstractThis report documents five critical success factors related to technology and market relationsidentified by the Momentum consortium in the implementation and scale-up of telemedicine inEuropean health systems. Each critical success factor is described in depth and analysed in seventelemedicine services from Germany, Israel, Italy, the Netherlands, Norway, Spain and Sweden. Thecases represent the different successful implementations of telemedicine in both private and publicinitiatives and both doctor-to-doctor and doctor-to-patient types of services.

Key Word List

eHealth, Interoperability, Implementation, Market, Procurement, Scale-up, Technology,Telemedicine

D7.2 - “Technical infrastructure and market relationsreport for the blueprint validated by ‘doers’ andstakeholders”

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Note on the telemedicine cases

The six telemedicine cases described in this deliverable can be located on the MOMENTUM website,called service descriptions, under six countries (Israel, Italy, the Netherlands, Norway, Sweden, andSpain): http://telemedicine-momentum.eu/europe/. A short description of each of the cases(including the Germany Patientenhilfe case) is also included in deliverable D3.2. In this particulardeliverable, the critical success factors are not examined in relation to the Patientenhilfe case.

Change HistoryVersion History:

01 25-07-201402 08-08-201403 29-08-201404 05-09-201405 05-09-201406 05-09-201407 06-09-201408 10-09-201409 12-09-201410 15-09-2014

Version Changes

01 Initial version subject to first review.02 Reviewed version and enhanced with insights from reviewers and cases.03 Reviewed version by project coordinator and addition of synthesis subchapter.04 Sub-sections on overall analysis added; sub-titles and their locations (e.g., creation of

new 2.12-6.12) crosschecked; consistent spelling of ITHACA added.05 Revisions made by Tino Marti.06 Revisions suggested by Marc Lange.07 All revisions reviewed by Diane Whitehouse.08 Revisions made by Tino Martí and elaboration of executive summary.09 Small textual modifications as early quality control by Diane Whitehouse.10 Quality review by Michael Strübin

Statement of originalityThis deliverable contains original unpublished work except where clearly indicated otherwise.Acknowledgement of previously published material and of the work of others has been madethrough appropriate citation, quotation or both.

http://telemedicine-momentum.eu/europe


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Table of Contents

EXECUTIVE SUMMARY III

1. INTRODUCTION 1

2. ENSURE THAT THE APPROPRIATE INFORMATION TECHNOLOGYINFRASTRUCTURE AND EHEALTH INFRASTRUCTURE AREAVAILABLE 2

3. ENSURE THAT THE TECHNOLOGY IS USER-FRIENDLY 8

4. PUT IN PLACE THE TECHNOLOGY AND PROCESSES NEEDED TOMONITOR THE SERVICE 12

5. MAINTAIN GOOD PROCUREMENT PROCESSES 16

6. GUARANTEE TECHNOLOGY HAS THE POTENTIAL FOR SCALE-UP 20

7. CONCLUSIONS 23

8. GLOSSARY: DEFINITIONS AND ABBREVIATIONS 24

9. BIBLIOGRAPHY 26

Table of Figures

FIGURE 1. CALLIOPE COMMON WORKING MODEL.................................................2


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Executive summary

Momentum’s collaborative work has the purpose of elaborating a Blueprint that validates aconsolidated set of methods supporting the telemedicine service implementation process.The Blueprint is structured in four dimensions and 18 critical success factors that atelemedicine service has to take into account to implement and deploy the service frompilot to routine care in a successful way. The four dimensions encompass strategymanagement, organisational management, legal and security issues and technicalinfrastructure and market relations.

This report contains the analysis of the technical infrastructure and market relationsidentified for mainstreaming telemedicine deployment in daily practice by means of fivecritical success factors:

Ensure that the appropriate information technology and eHealth infrastructure areavailable.

Ensure that the technology is user-friendly. Put in place the technology and processes needed to monitor the service. Maintain good procurement processes. Guarantee that technology has the potential for scale-up.

Throughout the revision of different telemedicine services from a small number of countriesin or near Europe (Israel, Italy, the Netherlands, Norway, Spain and Sweden) that made theleap from pilot to routine care, each critical success factor has been defined anddocumented. The cases represent several configurations in terms of ownership (public andprivate) and types of end-user (health professionals and patients) which makes themapplicable to multiple other telemedicine scenarios.

All five critical success factors were present in the cases reviewed although slight differenceswere found between public and private promoted cases due to their different missions:either to reach wider market bases or to deploy telemedicine at large scale in anorganisation or health system.


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1. Introduction

Telemedicine services are the practice of medicine at a distance. While there were someearly telemedicine experiences using first generation telecommunication systems such asthe radio or the telephone, the expansion of modern information and communicationtechnologies has brought a wave of innovation in the telemedicine field.

Implementing telemedicine services is a multi-faceted challenge. Telemedicine doers havefaced such challenges as cultural resistance from patients and health professionals,technological difficulties and organisational upheavals during telemedicine implementation.As a result, many telemedicine initiatives hardly manage to proceed further than a pilotphase.

Modern healthcare requires introducing new ways of producing and delivering cure fromdiseases and caring. They can help to deal with current societal challenges such as healthyageing, equitable access and the burden of chronic diseases. Telemedicine is a long-termsustainable type of service that still needs initial investment and continuous support until itovercomes the tipping point of its learning curve.

This report focuses on five current success factors identified in the technological and marketrelations domain that have been observed in six telemedicine services deployed in differentEuropean regions or nations.

Experiences from Israel, Italy, the Netherlands, Norway, Spain and Sweden serve as the basisto describe and analyse the contribution of the following five critical success factors totelemedicine service deployment: information technology (IT) infrastructure and eHealthinfrastructure; user-friendliness; service monitoring and maintenance; good vendorrelations; and the service’s potential for scale-up.



2. Ensure that the appropriate information technologyinfrastructure and eHealth infrastructure are available

This section of the report describes the issues surrounding ensuring that the appropriate ITand eHealth infrastructures are available at the time of deployment and scale-up.

2.1 What this critical success factor isThis critical success factor means ensuring that the appropriate IT infrastructures andeHealth infrastructures are available so that the telemedicine implementation can rely onthese infrastructures from the initial deployment to the last stage of the scale-up phase.

The distinction between IT infrastructure, eHealth infrastructure and eHealth services suchas telemedicine is represented in the working model developed by the CALLIOPE project in2011 (see the figure below).1

Figure 1. Calliope Common Working Model

IT infrastructure consists of all the active elements in IT operations. A typical ITinfrastructure includes the following elements: hardware, software, networks (includinginternet connection and security systems) and the IT staff responsible for network, hardware

1 Available at: http://www.calliope-network.eu. To the three layers of the project, the Momentum project hasadvanced the pillar entitled “eHealth Governance”, which is related to the critical success factors addressed bythe two Momentum deliverables, D4.2 “Strategy and Management” and D6.2 on “Legal, regulatory andsecurity issues”.

http://www.calliope-network.eu/



and software development and maintenance. All together have the mission to supply access,storage and processing capacity to the service users.

In the context of telemedicine, IT infrastructure is the set of industry-neutral infrastructureelements (available for all sectors) that supports the successful deployment and goodfunctioning of new healthcare services.

eHealth infrastructure is a sector-specific subset of the IT infrastructure. It includeshardware, software or networks designed specifically for healthcare provision. For instance,health information systems incorporate elements such as electronic health records orpatient health records able to capture, store and distribute clinical data across differentlevels of care and among different health providers and patients.

The communication of health data may require interoperable health information systemsthat follow clinical terminologies, codifications and data exchange standards such as DICOM,HL7 or SNOMED.2

2.2 ObjectivesThe main objectives of this critical success factor are related to the efficiency and theinteroperability of the telemedicine service.

First, ensuring that these infrastructures are available is crucial to reduce development andimplementation costs of telemedicine services by relying on and using existing IT andeHealth infrastructures without risking the quality of the new service or its obsolescenceover time.

Second, using available IT and eHealth infrastructures means that the new telemedicineservice is embedded in current information systems. It guarantees the service’sinteroperability with other healthcare services or healthcare providers. Stand-alonesolutions run the risk of being refused by end-users.

2.3 The context surrounding the success factorThe need for eHealth infrastructure criticality varies depending on the type of telemedicineservice initiative. In the case of private vendor initiatives that aim to sell telemedicineservices in a healthcare market, the design of interoperable solutions to their potentialcustomers is fundamental. In the case of public or private provider initiatives, the criticalpoint is the scale of the implementation plan measured by the number of organisations orcentres that will be involved and the diversity of health information systems that theyoperate.

Complex eHealth infrastructure contexts (for example, when there are at least two healthinformation systems operating together, even within the same healthcare organisation)require health data integration i.e., interoperability.

2 See section 8 of this deliverable for a glossary of terms.



Another contextual factor is the type of telemedicine service involved. In doctor-to-patientinitiatives, the availability of appropriate IT infrastructure is of more influence in theimplementation than the eHealth infrastructure. The latter has a larger influence in doctor-to-doctor initiatives because health professionals expect health information systemsintegration to better support the care on offer.3

In the telemedicine field, access to electronic health records and clinical data provided byother health providers may be needed in order to share data and avoid data silos. Here, thehealth system configuration will be important, as better data integration in health systemswith a strong IT stewardship will be expected.

2.4 First thoughts on pre-requisites underlying the success factorPublic or private telecommunication operators will have had to invest in a network ITinfrastructure (i.e., broadband) that is mature at the time of implementation.

The health information system that will capture telemedicine data must be ready to acceptdata from third-party sources through intercommunication systems (such as web services)or evolve in parallel with the telemedicine implementation to accommodate these datainteroperability needs.

2.5 Illustration of this critical success factor from the Maccabi caseThe Maccabi chronic disease management service is based firmly on a number oftechnological features that help to show that the initiative is a modern healthcare case.

The Maccabi example encompasses the use of an electronic healthcare record system that isused with other Maccabi applications, a computerised central medical record, acomputerised call centre management and patient management infrastructure,computerised clinical protocols embedded in the electronic healthcare record and avideoconferencing and telemonitoring system to communicate with patients who are athome. Together, all these technological elements act as a global telemedicine service fordelivering high quality care to patients with chronic conditions.

The interoperability of the infrastructure is critical for the Maccabi institution and itshealthcare professionals so as to facilitate transitions of care and integrate the full cycle ofcare whether the care is provided face-to-face or virtually.

2.6 Illustration of this critical success factor from the RxEye caseBecause RxEye is a Swedish eHealth solution designed to provide radiological knowledge andadvice from the distance, the system was built to serve different clients. It consists of a webplatform for transmission and radiology image reading and reporting. It relies on theavailable broadband infrastructure and uses standard data communication systems over thenet (both HTTP and FTP).

3 Here, the notion of a doctor includes all kind of other health professionals.



The quality of the teleradiology reporting service depends on the availability of digitalisedreferral letter, clinical data, previous imaging reports and images, current examinations, andother reports. Existing eHealth infrastructure is mandatory for achieving a similar quality ofservice with teleradiology as with on-site radiology.

In terms of interoperability, the nature of this radiology-related service required it to beconnected with customers’ PACS and radiology information systems.

2.7 Illustration of this critical success factor from the Teledialysis caseThe Norwegian teledialysis service is a telemedicine service based on synchronous video andaudio two-way communication. It required a pre-established broadband network to allowreal-time communication. The Norwegian broadband network was mature at the time of theteledialysis service implementation and this thus helped the service to be rolled out withoutproblems.

The videoconference solution adopted by the teledialysis service was off-the-shelfequipment (Cisco TelePresence System Edge 95)4 which brought reliability and reducedimplementation risks that could otherwise have been faced with newer IT developments.

Interoperability was involved when accessing the electronic health record available duringdoctor-to-patient consultation and in recording documentation of the treatment. Initially,the staff in the local units and in the university hospital documented the patient treatmentin the same electronic healthcare record. Then, the local units installed new dialysismachines with a documentation system incompatible with the electronic healthcare recordsystem at the university hospital. Therefore, they stopped documenting patient treatmentsin the same system.

There also turned out to be some legal hindrances since the (then) newly passed NorwegianHealth Register Law prohibited employees in one health institution from documentingpatient treatment in another health institution’s electronic healthcare record.

2.8 Illustration of this critical success factor from the ITHACA caseITHACA was conceived as a consortium venture in which three different organisationsbrought together their capacities to build a new telemedicine service for patients with bloodpressure disorders.

Indra5 was the venture partner responsible for IT development. It is a Spanish IT and defencesystems company with broad experience in developing complex IT solutions for a range ofdifferent industries including healthcare.

The solution developed by Indra had to be integrated with Badalona Serveis Assistencials(BSA) health information systems. The interoperability of this connection became mission-

4 Fact sheet: http://www.cisco.com/c/en/us/products/collateral/collaboration-endpoints/telepresence-system-edge-mxp-series/data_sheet_c78-628575.html5 More information about Indra is available at: http://www.indracompany.com/en/sobre-indra/compania-global-de-ti

http://www.cisco.com/c/en/us/products/collateral/collaboration-endpoints/telepresence-system-edge-mxp-series/data_sheet_c78-628575.html

http://www.cisco.com/c/en/us/products/collateral/collaboration-endpoints/telepresence-system-edge-mxp-series/data_sheet_c78-628575.html

http://www.indracompany.com/en/sobre-indra/compania-global-de-ti

http://www.indracompany.com/en/sobre-indra/compania-global-de-ti



critical in so far as it needed to avoid duplications in computerised physician order entry(i.e., there should not be two health records) and reduce clinical workload. Ultimately,ITHACA’s solution was successfully integrated with the BSA current electronic health recordin one direction, extracting data from BSA’s electronic healthcare record so as to display it inITHACA systems. ITHACA is fed by BSA electronic healthcare record data so that clinicians donot have to feed data manually into the ITHACA system.

ITHACA is a solution based on telecommunications standards for data exchange (such asWWW and SMS) and voice communication (GPRS).

2.9 Illustration of this critical success factor from the KSYOS caseTo ensure deployment of KSYOS’s own system, both IT and eHealth infrastructures werecritical to deliver its telemedicine services. KSYOS understands criticality as the appropriatecombination of a reliable IT infrastructure and the capacity to interoperate with customer’sinformation systems to reduce workloads and increase quality and customer satisfaction.

KSYOS considered IT infrastructure in its second phase of development when usabilityresearch was performed and in its fourth phase when the company scaled up its solutions.

2.10 Illustration of this critical success factor from the Cardio OnlineEurope case

The telecardiology system of Cardio Online Europe definitely pays particular attention to ITinfrastructure as it depends on it to deliver timely urgent care.

The service has the most recent hardware technology (Cardiovox P12 and Cardiolink)6, whilethe software used for the heartline receiving system works on an Oracle database. In 2013,Oracle developed a new hardware product with all the best features for the scope of thistask. This Oracle database application, on a scale of values, ranks in one of the top places interms of performance.

Cardio Online Europe has three levels of networks that are synchronised with its database.Electricity and telephone dashboards are tested daily by technical staff. The service also hasanother room in the same office for a central telecardiology backup system.

The output file of the electro-cardiogram (ECG) report can be downloaded in real time fromthe internet as a jpeg or pdf file. The heartline receiving system data files and database areinteroperable with the health information systems.

Because IT infrastructure must always be functional, in Cardio Online Europe’s case, thiscritical success factor can be seen to be closely associated with another critical successfactor: that of service monitoring.

6 More information about Cardio Online Europe technology is available at:http://www.cardioonlineeurope.com/pagina.php?azienda=1

http://www.cardioonlineeurope.com/pagina.php?azienda=1



2.11 Lessons learned on information technology infrastructure andeHealth infrastructure from the cases

Appropriate IT infrastructure was found to be relevant in the implementation of all the casesreported on. The maturity of communication systems developed in the last decade has,without doubt, contributed to easing development and acceptance of telemedicine services.The use of technology standards is a guarantee of success and efficiency, as has beenspotted in various cases: videoconference in Teledialysis, web development standards inMaccabi, ITHACA and KSYOS, and communication standards in all six cases.

Interoperability supported by appropriate eHealth infrastructure has differed among thecases. On the one hand, in those cases which are private initiatives and are oriented to themarket (such as KSYOS, RxEye and Cardio Online Europe), to deploy integration withcustomer health information systems was critical to success. On the other hand, eHealthinfrastructure has been proven fundamental to enable de facto scaling-up in the Maccabicase and the potential to scale up in ITHACA and Teledialysis.

Moreover, eHealth infrastructure has brought quality of care and efficiency to thesetelemedicine services. In the Maccabi case, system integration was a guarantee of highquality care, while in all cases it helped to avoid duplications and errors in data entry.

2.12 Overall analysis on information technology infrastructure andeHealth infrastructure from the cases

The appropriateness and availability of information technology infrastructure and eHealthinfrastructures was illustrated by all cases. At the present time, technology has reached thematurity level to allow the application of telemedicine solutions in a safe and reliable wayfor all types of users. However, a difference in the scaling-up approach was detectedbetween cases based on the nature of their configuration. Private and market-orientedcases (such as RxEye, KSYOS and Cardio Online Europe) followed closely technologystandards, and they were keen on adopting interoperability standards to maximise theirmarket opportunities. On the other hand, public sector-promoted cases (Maccabi,Teledialysis and ITHACA) relied on interoperability standards to improve their scalingcapacity.

2.13 Further relevant discussionOften, IT or eHealth infrastructures are not in place. Health and clinical information systemsare often only partially deployed. Interoperating with them can be difficult in addition tobeing very costly. Paradoxically, the smaller the size of the telemedicine initiative, thegreater the resulting budget burden of IT infrastructure is due to economies of scale.

The time dimension of technology solutions’ availability is as important as the spacedimension. Some telemedicine solutions are so advanced that they encounter adoptiondifficulties due to a lack of technological skills or technological awareness on the part ofinstitutions and health professionals or even patients. It is therefore important to ensurethat technology is in the right place at the right time.



3. Ensure that the technology is user-friendly

This section of the report describes the issues surrounding ensuring that the technologyused in the telemedicine deployment is user-friendly.

3.1 What this critical success factor isThis critical success factor means making sure that the technology used in the telemedicinedeployment is user-friendly. The technology referred to here relates not only to end-userdevices and displays but the whole system configuration.

User-friendliness is a combination of attributes from both technical and human dimensionsthat helps the user to learn and adapt easily to a new technological environment (Lehoux2004). These attributes include simplicity, responsive design, and usability. Users adoptinnovation easily when they perceive it as simple and easy-to-use. Responsive design is amethod to achieve simplicity and usability through user-centred design. User-centred designis mainly achieved through user involvement in the design process. Simplicity and usability intechnology is also related to the use of standards that reduce unnecessary technologicaldependencies.

From a technological perspective, all these features together should bring fitness forpurpose, cost efficiency, ease of understanding and use, and reliability to all telemedicineservice users. Thus, user-friendliness in a telemedicine service is critical to increase thespeed of user adoption and avoid rejection by end-users.

3.2 ObjectivesUser-friendliness has two objectives. On the one side, it aims to make the technology easy touse by an average user (whether the user is a health professional or a patient) without theneed for a long learning curve or an extended training period or process. On the other side,the technology has to be reliable both at device and system level.

3.3 The context surrounding the success factorThe technological and organisational context where the new solution is set up determinesthe level of environmental complexity. For example, the co-existence of multiple healthinformation systems or having a heterogeneous user base (i.e., involving a mix of differenttypes of users with a range of different skills) may require an additional effort being madetowards user-friendly design.

This will help to avoid users experiencing feelings of complexity, particularly when healthprofessionals have to work with different information systems.

When the telemedicine service end-users are the patients, the human dimension of user-friendliness is even more important for the system to be accepted by a diverse user base.



3.4 First thoughts on pre-requisites underlying the success factorTwo pre-requisites are important when developing user-friendly technology: they aresimplicity and eHealth literacy.

Simplicity is a subjective experiential factor that is measured by end-users. It may determinethe degree and speed of adoption.

The level of eHealth literacy (that is, e-skills applied to healthcare) (Chan et al 2009) of bothhealth providers and patients will ultimately be a pre-requisite for the success of this criticalsuccess factor. Earlier exposure to IT-based healthcare helps end-users to adopt newtelemedicine services more easily. Moreover, the work done in change management planscan improve the point of departure in terms of eHealth capacities.

3.5 Illustration of this critical success factor from the Maccabi caseUser-friendliness is a critical success factor in the Maccabi service as the target patientpopulation is not necessary tech-savvy. For instance, the tablets used for video conferencingbetween patient and nurse have only one use. Hence, the patients have only to touch onebutton to connect with their nurse. Those patients who do not have tablets contact theirnurses by telephone.

3.6 Illustration of this critical success factor from the RxEye caseRxEye service depends critically on the fact that the teleradiology service should not changeroutines in the radiology department which is outsourcing reporting. RxEye service does notrequire major changes in local software or hardware setup. The technical platform iscommon for all functions and products. The teleradiology buyer should make a singleinfrastructure installation and integration with its own information system.

3.7 Illustration of this critical success factor from the Teledialysis caseThe technology deployed in Teledialysis is not very complicated and it was user-friendly fromthe outset through its own design. The system is flexible in the way that not all thepossibilities are used at all times, but are adapted to the actual needs of the end-users.

3.8 Illustration of this critical success factor from the ITHACA caseInspired by its patient-centred framework, ITHACA is a user-friendly solution. Its user-friendliness has been validated by the different satisfaction surveys performed with regardto the service. Patients may access ITHACA services in different ways, including via letters,telephone, or interactive web-based services.

3.9 Illustration of this critical success factor from the KSYOS caseUser-friendliness and safety were two aspects particularly encompassed in the second phaseof KSYOS’s development: when it undertook internal and external testing and usabilityresearch. The goal was to assure end-users, both general practitioners and hospital



specialists, that they would feel comfortable using KSYOS interfaces and ensure that theywould engage immediately with its functionalities.

Any potential steepness in the adoption learning curve was reduced through an enhanceduser-friendly design.


The electrocardiographs used in the Cardio Online Europe case (which are Aerotel medicalsystem Cardiovox P12) are extremely easy to use and have a user-friendly design.

By pressing only one button, the doctor records and, in a few minutes, sends a 12 leadsstandard electrocardiogram. The transmission involves acoustic coupling. The soundproduced can be transmitted by every telephone system, from the ambulance’s telephone,from the doctor’s phone, from the patient’s home, or from any device capable of making aphone call.

Cardio Online Europe is aware that other communication systems exist. But the companyalso knows that every signal transmitted by the internet or any other digital system must beelectronically transmitted from start to end. If not, the trace cannot be recognised. For thisreason, the company has opted for an analogue solution, because the sound produced byCardiovox P12 can be transmitted in every transmission mode.

3.11 Lessons learned from the casesMaccabi and ITHACA have patients involved as telemedicine service end-users. Theirsolutions offered a wider range of accessibility to cover the diversity of chronic care patientsand stressed the importance of simplicity in user interfaces to compensate the risk ofcomplexity of a multi-channel approach.

The rest of the cases reviewed (RxEye, Teledialysis, KSYOS and Cardio Online Europe) weredoctor-to-doctor types of telemedicine service where healthcare quality and safety, and usercomfort, were crucial so as to be accepted as an alternative care service by the healthprofessionals involved.

In conclusion, user-friendliness is mission critical in accelerating user adoption oftelemedicine services and reducing the risk of rejection due to a lack of usability.

3.12 Overall analysis on user-friendly technology from the casesUser-friendliness was fundamental in the design and implementation phase in all the casesreported on to guarantee and support an easier user adoption. A different approach tousability was clearly identified among those cases which depend on their orientation on end-users. The cases typified as doctor-to-doctor telemedicine services focused on usability toavoid additional data-entry and reduce clinicians’ workload while doctor-to-patient cases(such as Maccabi and ITHACA) focused on usability in terms of accessibility to patients.



3.13 Further relevant discussionUser-friendliness benefits when end-users are involved in the design process. As the ChristieCommission of the Scottish Government on the future delivery of public services proposed,effectiveness can be further increased through bottom-up design approaches andparticularly throughout the involvement of people and communities. Usability should beincluded in the design and deployment processes (Christie 2011).



4. Put in place the technology and processes needed tomonitor the service

This section of the report describes the issues surrounding putting in the place thetechnology and processes to monitor the service.

4.1 What this critical success factor isService monitoring is the function of guaranteeing that the telemedicine service is up andrunning without any form of excessive delay in routine use or technical interruption – exceptfor those interruptions scheduled for system maintenance. Service monitoring includes allactivities to govern IT such as maintenance plans, security issues, service continuity, helpdesk, access management.

The introduction of technology in healthcare practice has to avoid at all costs time losses onthe part of the clinicians, as this is a big source of frustration to them as it may prevent themfrom caring for patients. Therefore a good quality technology services monitoring service isimportant so as to guarantee continuity of care.

Service monitoring may be provided either internally by the healthcare service provider orexternally through a contractor.

It is also important to consider the needs of end-users in order to identify possiblerefinements that improve adoption and use of the service. Staff members involved in servicemonitoring are in a privileged situation in terms of capturing end-users’ needs as their mainactivity is trouble-shooting.

4.2 ObjectivesA successful telemedicine service monitoring implementation has the following objectives.Service monitoring is intended to:

Guarantee a continuous level of service. Solve any incident that may occur during the service. Support end-users in resolving any doubts that they might experience.

Besides these three objectives, it is also important to understand the context surroundingthis critical success factor.

4.3 The context surrounding the success factorThe level of structuring of the service monitoring will probably depend on the type of servicecontracted or developed, and how long the service has been running. It will also beimportant to define who is providing this service in the case of a joint venture: it may be thesame company that develops the service or it may be a third party that is responsible formaintenance and service contracts.

Other contextual factors are the type of synchronicity (online as compared to offlineservices) and the scale of the telemedicine service in terms of its size and the number of



organisations involved. The larger the scale or the customer base, the more critical thissuccess factor becomes.

4.4 First thoughts on pre-requisites underlying the success factorAs an after-sale type of services, service monitoring may or may not be included in thecontracted or developed service. The telemedicine doer needs to verify the specificity of anyservice level agreements in the signed final contract to avoid any lack of compliance withany of the objectives described for service monitoring.

4.5 Illustration of this critical success factor from the Maccabi caseIn the Maccabi case, that of a large healthcare organisation chronic disease managementservice, IT service monitoring is critical to the long-term sustainability of the service. As alarge-scale implementation within this healthcare organisation, IT monitoring is mostly doneby Maccabi’s IT department. External providers, like the company that is providing thetablets (Avaya) as well as a telephone company, support Maccabi’s maintenance team.

4.6 Illustration of this critical success factor from the RxEye caseService monitoring has a double role in the case of RxEye. The nature of this service, whichinvolves the outsourcing of radiology diagnosis, requires a joint effort from an ITperspective. On the one side, RxEye needs to be available to receive radiological images andsend diagnostic reports to its healthcare clients. On the other side, the client IT system hasto be able to store and send radiological images and receive, store and integrate radiologydiagnostics into its health IT infrastructure. Therefore, a good collaboration with thecustomer’s IT governance team(s) is important to deliver a good service level.

4.7 Illustration of this critical success factor from the Teledialysis caseThe IT system involved in Norwegian teledialysis is based on three main technologicalelements:

A videoconferencing system over internet protocol. Medical equipment capable of being used with the assistance of a local nurse or

physician assistant (e.g., ultrasound, an electronic stethoscope and a dialysismachine).

A health information system to store and access patient data (in the electronichealth record).

Therefore, service monitoring has to ensure the maintenance of all three types oftechnologies (video conferencing; medical equipment; and a health information system)which involve a diverse maintenance team. In this case, it is the same organisation whichmonitors and supports all the IT systems at the hospital.

4.8 Illustration of this critical success factor from the ITHACA caseServices maintenance and monitoring was outsourced to Indra, the technological partner inthe ITHACA venture. Indra is used to large technological projects in different sectors. In the



case of ITHACA, it has provided excellent service maintenance to date and has developednew features of the web platform as required by BSA.

4.9 Illustration of this critical success factor from the KSYOS caseKSYOS paid attention to the quality of service monitoring in its fourth phase of activityduring which its services were scaled up to routine care in a large customer base. For KSYOS,scale was a determinant of the back-office infrastructure that is required to guaranteeuninterrupted service. KSYOS executives adopted a proactive approach to maintenance,actively monitoring the service performance to improve user experience.


Telecardiology services offered by Cardio Online Europe in Puglia region are supported by anIT infrastructure that needs to be fully functional on a 24/7 basis to receive, read andtransmit electrocardiograms. Due to the medical criticality of this support, servicemonitoring is crucial. More than a third of the electrocardiograms sent are received duringnight shifts, and 12% of patients have reported serious diseases.

Cardio Online Europe has a dedicated section in its customer satisfaction survey to check thecustomers’ satisfaction with service monitoring. The section contains questions consideringthe needs of users that range from issues around instructions for use to technical assistance.Cardio Online guarantees the replacement of devices within 24 hours from any callrequesting support. Devices are tested frequently. Every five years, the equipment iscollected and sent to check-up centres, which is what the law stipulates.

4.11 Lessons learned on putting the technology and processes in placeneeded to monitor the service from the cases

Two out of the six cases reviewed had internal service monitoring (Maccabi and Teledialysis).In the case of Maccabi, the quality assurance of a big scale-up in a large healthcareorganisation motivated the decision whereas, in Teledialysis, it was supported by the diversemaintenance requirements of the telemedicine service. In the other four cases (RxEye,ITHACA, KSYOS and Cardio Online Europe), service monitoring was provided by externalsuppliers in the case of ITHACA, and by their own telemedicine companies in the remainingcases. It is not unexpected that service monitoring is part of the value proposition oftelemedicine vendors.

What can be learned from these cases is the importance of a good form of collaborationorganised with customers’ IT governance teams in order to guarantee a high level of serviceand integration.

Two other significant lessons are the importance that service monitoring has to do with thescale of the telemedicine service (Maccabi), and the criticality of the healthcare serviceprovided (Cardio Online Europe).



4.12 Overall analysis on the technology needed to monitor the servicefrom the cases

The technology and processes required to provide a continuous and reliable maintenanceand telemedicine service monitoring was present in all cases. Vendor initiatives had servicemonitoring as a key value proposition. Healthcare providers opted to internalise the servicewith the exception of ITHACA. In ITHACA’s case, this option was not selected due to itspartnership with an IT company. In all cases though, a good collaboration among servicemonitoring teams and technology providers was seen as crucial to guarantee the quality ofthe service.

4.13 Further relevant discussionService monitoring needs to be tackled from a dynamic perspective. It has a present aspectand a future aspect. It is not enough simply to guarantee a well-functioning system at thepresent time. It is also necessary to explore how maintenance will adapt to future changes inthe technological and administrative environments, and how these changes will besupported financially. Often, it is the service monitoring team that is in charge of furtherdevelopments of the technological – mainly software – infrastructure to support thetelemedicine service.



5. Maintain good procurement processes

This section of the report describes the issues surrounding ensuring good procurementprocesses.

5.1 What this critical success factor isGood procurement processes involve two main focus areas: content and method.

As for content, any service that is contracted may be delivered with a wide range of qualityvariability. Unless these aspects are specified in the contract signed with telemedicineproviders, the risk is fully transferred to the procurer. A good practice in good procurementis to specify these aspects in a transparent, straightforward service level agreement to besigned by contracting parties.

By method, we refer to the formal process of procurement as a guarantee of the quality ofthe final output, the purchase. This encompasses issues of transparency and competitionpresent in procurement legislation derived from a European directive on public procurement(Directive 2014/24/EU).

5.2 ObjectivesGood procurement processes aim to ensure the fairness of the relationship between theprocurer and the provider, the quality of the service during the terms of the contract and, inthe case of public procurement, to guarantee the competition of different providers.

Quality is ensured by the underwriting of service level agreements and contracts that clearlydefine what it is expected from both parties and what are the specific rights and liabilities ofengaging in the particular telemedicine project or initiative.

5.3 The context surrounding the success factorHealthcare organisations have to be accountable for their operations to differentstakeholders. In the case of public institutions, this is legally reinforced by the obligation tobe compliant with the relevant public sector public procurement laws derived from aEuropean Union directive. This type of legislation regulates how the procurement processhas to be undertaken in terms of competition, publicity and duration.

Private organisations enjoy a higher degree of freedom in their procurement methods butremain accountable to their boards of trustees and may regulate internal procedures withwarranties similar to those practiced in the public sector. Public-private initiatives introducean additional complexity into the procurement process as the solution to be found has a pre-commercial character.

Procuring telemedicine services has a particular feature related to contracting services basedon data. Data protection and privacy issues are at stake and have to be formally addressedin the contract clauses.



5.4 First thoughts on pre-requisites underlying the success factorA facilitating characteristic in the contracting process is the availability of guidelines andservice level agreement templates used in previously contracted services that may guidenew procurers of services to avoid any past errors.

In classical procurement, the market needs to be large and competitive enough to be able todeliver the required technology whereas, in pre-commercial procurement, the market needsto be ready to step in and hence to have enough of a business perspective (Bos 2008).

5.5 Illustration of this critical success factor from the Maccabi caseMaccabi’s procurement department experience enabled it to procure the array of servicesneeded by means of a set of clear contracts that defined the appropriate deliverables,schedules, maintenance and responsibilities. Clarity in the procurement process (what isexpected and what will be provided) was considered to be critical to the success of theimplementation of the service.

5.6 Illustration of this critical success factor from the RxEye caseRxEye dealt with the contracting process as a provider rather than as a client. As atelemedicine service provider, RxEye has relied on flexible and secure online contracts toguarantee the level of service provided and data protection. RxEye is providing customerswith the software to send and receive referral letters, images and reports, to buy and sellmedical image reporting, and to make contracts between parties. In this regard, RxEye is avendor: according to its service level agreement and other contractual conditions, it shoulddefinitely provide support, maintenance and development of the system.

5.7 Illustration of this critical success factor from the Teledialysis caseThe managers of Teledialysis had access to experts on video conference equipment in orderto define the necessary requirements for the “package” (a configuration of solutions andprocurement knowledge). They also had access to the general procurement expertise at thehospital.

5.8 Illustration of this critical success factor from the ITHACA caseGood vendor relations were secured through contracts and agreements among the threepartners in the telemedicine initiative, BSA, Indra and Novartis. The impetus to formaliseagreements came from all partners as potential for scalability was foreseen from each party.For instance, Novartis envisioned to extend the ITHACA system to other pathologies relatedto its therapeutic lines (in the fields of cardiovascular, respiratory or endocrinology). Indrawas comfortable acting as a technological provider for ITHACA as well as to be able to exportthe solution to new customers.

In terms of counselling, BSA obtained legal advice from its procurement department which itused to draft and issue service contracts to support healthcare delivery. Novartis and Indrawere also assisted by their own legal departments.



5.9 Illustration of this critical success factor from the KSYOS caseIn the case of KSYOS, the character of this critical success factor needs to be understood inthe same way as in the case of RxEye.

KSYOS acts as the vendor rather than the client. The company developed a telemedicinetechnical solution that is marketed jointly with medical diagnostic and consultation services.So, good procurement practices were scoped during KSYOS’s fourth phase of development.In this phase, it scaled up its services and offered them to various medical groups through aset of different contracts and agreements that covered both the near-term and long-term.


Cardio Online Europe regards good practice with vendors from a similar position as that ofKSYOS and RxEye. All are providers of a telemedicine solution, so they handle this criticalsuccess factor differently from several of the other cases.

Cardio Online Europe delivers services to the public health care system in the Italianprovince of Puglia as well as to private hospitals with which it has signed collaborationcontracts. Therefore, the Puglia region acts as the procurer. In these contracts, service levelagreements are laid out that Cardio Online Europe has to fulfil.

5.11 Lessons learned on maintaining good procurement practices fromthe cases

Particularly when care teams are experiencing telemedicine for the first time, anyuncertainty involved in the telemedicine services can act as a recommendation for reducingambiguity through the signature of clear service level agreements. In the procurementprocess, specifying with clarity the various functions and deliverables of the service is acornerstone both for clients and providers of telemedicine services. In order to streamlinethis process, having access to expertise in their procurement departments appeared to beindispensable to the Teledialysis and ITHACA projects.

This factor emerged as primary in the case of ITHACA, where a public-private partnershipwas formed to develop the telemedicine service. Clarity in the procurement process, andhaving an agreed business plan, may help to define the levels of responsibility, ownershipand further developments, thus uncovering the venture partner’s agendas.

As providers of telemedicine services to healthcare organisations (which was the case interms of RxEye, KSYOS and Cardio Online Europe), having good procurement processesproved to be relevant as most of their potential customers have to follow publicprocurement legislation.

Despite the fact that none of the cases explored reported on following a pre-commercialprocurement process, one may consider that public initiative cases (like Maccabi,Teledialysis or ITHACA) were in fact pre-commercial developments: for example, all the risk



was borne by the healthcare provider in Maccabi and Teledialysis, and was partiallydistributed in the case of ITHACA.

5.12 Overall analysis on maintaining good procurement processes fromthe cases

Clarity in the procurement process and access to expert advice was considered in all cases tobe critical in order to face better future developments of the telemedicine services. A lack ofguidelines in pre-commercial procurement was detected particularly in healthcare providers’initiatives (such as Maccabi and ITHACA).

5.13 Further relevant discussionProcuring telemedicine services is not an easy task. A high degree of uncertainty is presentboth in the design, development and deployment phases.

Innovative procurement methods have been developed in recent years. Systems likeinnovative public procurement or pre-commercial procurement are now being tested todevelop services that involve the interface of healthcare and technology. Particularly, pre-commercial procurement helps commissioners of services to reduce their level ofuncertainty and transfer part of the risks involved to competitive providers. As a result, theprocurement process has become more flexible (Edler & Georghiou 2007).

Telemedicine development and implementation is not a linear process. Uncertaintyincreases with the presence of multiple partners. In order to avoid confusion among thepartners involved in such an eHealth journey, a clear definition of roles and responsibilitiesas well as a determination of timelines and milestones has to be specified in the variousbinding documents associated with procurement processes.



6. Guarantee technology has the potential for scale-up

This section of the report describes the issues surrounding aiming to guarantee that thetechnology used has the potential to be scaled up.

6.1 What this critical success factor isThis critical success factor means considering that, from a technological standpoint, it maybe important to grow and extend the telemedicine service developed to a larger scale.

Therefore, the appropriate vendor and the right technology need to be chosen. Thepotential for scale-up can be achieved by using either standard technologies or technologiesthat are similar and yet are produced/offered by a range of suppliers. Failing to do this maywork in the short term and on a small scale, but will probably cause bottlenecks at thescaling-up stage.

6.2 ObjectivesThe telemedicine doer has to take into account what actions are needed to make the leapfrom pilot to large-scale deployment in both technological and commercial terms.

Scalability is directly related to the degree of standardisation of the technical solution asdefined by market adoption (de facto) or specified by a standardisation organisation (dejure).

6.3 The context surrounding the success factorWhen the telemedicine solution depends on a technology partner or provider, scalabilitymay be a condition of provider lock-in. Both the existence of a competitive market to avoidsupplier-dependency and the specifications in the contracts provide ways to be able to scaleup.

The size of the implementation foreseen also determines the potential for scale-up, takinginto account the surrounding level of organisational complexity.

6.4 First thoughts on pre-requisites underlying the success factorThe availability of technical standards, both de facto and de jure, is a pre-requisite to largescale-up, when the scaling involved encompasses different health economies or healthcareorganisations.

6.5 Illustration of this critical success factor from the Maccabi caseThe service was scaled up within the Maccabi organisation after a pilot phase involving 1,400patients. It reached 10,171 patients treated in July 2014 after two years of service. The factthat the large-scale deployment did not require a new health information integration or anew technological environment helped to enable the completion of the scaling-up process inonly several months.



6.6 Illustration of this critical success factor from the RxEye caseThe RxEye brokering platform has excellent properties which will enable it to be furtherscaled up as it interoperates with customer information system in a non-intrusive way(exchanging radiological image and reporting results). The earning logic depends extensivelyon the number of transactions made using the platform. In fact, the service has already beenscaled up inside Sweden and abroad, as it has become a provider to Danish customers.

6.7 Illustration of this critical success factor from the Teledialysis caseA regional scale-up (with more local health centres being connected to the hospital) woulddemand the redesign of the organisation and routines according to how many simultaneousvideo-conferences the renal department should and can handle.

As for a broader scale-up (i.e., connection with new hospitals or regions), no particularproblems are foreseen as the communication technology used is standard.

6.8 Illustration of this critical success factor from the ITHACA caseFrom a technological point of view, ITHACA is ready to be scaled up geographically (in otherareas in the Catalonia autonomous region) and functionally (to be used for other healthconditions, such as diabetes). However, this scale-up has not yet occurred, as a further scale-up agreement has so far not been possible due to differences among the ITHACA partnersand their divergent interests. Actually all three partners are desirous of scaling-up theservice, but in different ways. BSA would like to extend the service to more chronic carepatients, while Novartis and Indra would like to offer ITHACA to other healthcareorganisations worldwide.

6.9 Illustration of this critical success factor from the KSYOS caseKSYOS follow a Health Management Practice model that has been built on having fourphases. These phases are: service development, usability research, efficiency research, andscale-up. The scale-up phase focused specifically on deploying KSYOS services to new clientsand larger organisations.

However, from the very first phase, when the service was designed and developed, scale-upwas already taken into account and outlined in the KSYOS business plan (since technologyinfrastructure must be supported by company growth in terms of the number of clients andservices, such as teleopthamology, telecardiology, teledermatology, and telepulmonology).In KSYOS, expansion models and service adaptation were defined at the beginning of serviceextension.


For some years, the Cardio Online Europe service has been directed not only towards theemergency sector but also to either the severity or chronic character of the condition. Manypatients need care and regular health checks, so the Puglia region decided to make the same



technologies (i.e., electrocardiograms and Holter) available to those individuals whoexperience an emergency event. The aim of Cardio Online Europe is not to stop at scale-upin only one region, but to extend the same service to other Italian regions. This scaling-upoccurs when policy-makers and cardiologists agree, as it has been the case in the Pugliaregion. In 2014 Cardio Online Europe moved offices and more than tripled the size of itspremises.

6.11 Lessons learned on guaranteeing that the technology has thepotential for scale-up from the cases

All cases have experienced scale-up in some way. Maccabi, RxEye, KSYOS and Cardio OnlineEurope have deployed their service to different care teams than in the first deploymenteither inside the organisation (Maccabi) or to new customers (the rest of the cases). ITHACAand Teledialysis have deployed telemedicine only in a first care environment, but both hadplans to scale-up from the beginning. The cases show how important it is to incorporatescale and scope in early planning stages and how this influences technology selection,procurement processes and organisational issues.

Regarding the technological market, innovative technologies may over-promise and may berisky when compared with more established technologies in terms of customer acceptabilityor the availability of technology providers.

Avoiding provider lock-in and assuring potential interoperability with different healthinformation systems through the use of technology standards are two relevant lessons fromthe ensemble of telemedicine experiences that have been reviewed.

6.12 Overall analysis on guaranteeing that the technology has thepotential for scale-up from the cases

All the cases considered an attachment to mature and standard technologies andinteroperability to be fundamental in order to scale-up their solutions.

6.13 Further relevant discussionScalability is not only a technological issue. It also encompasses three other perspectives –geographical, functional and target perspectives. For this reason, scaling-up has to beaddressed seriously from the beginning of a telemedicine project or initiative.



7. Conclusions

All five critical success factors that define the technical infrastructure and market relationsblock of critical success factors have been validated through the analysis and illustration ofselected telemedicine cases.

The appropriateness and availability of information technology infrastructure and eHealthinfrastructure was illustrated by all the cases. At the present time, technology has reached asufficient level of maturity to allow the application of telemedicine solutions in a safe andreliable way to all types of users.

However, a difference in the upscaling approach was detected between cases based on theirconfiguration. Private and market-oriented cases (like RxEye, KSYOS and Cardio OnlineEurope) followed technology standards closely and were keen to adopt interoperabilitystandards so as to maximise their market opportunities. The public-sector promoted cases(Maccabi, Teledialysis and ITHACA), which relied on interoperability standards, in contrastneeded to have a good integration with their own electronic health records and to improvetheir internal scaling capacities.

User-friendliness was fundamental in the design and implementation phase in all the casesto guarantee and support an easier user adoption. A different approach to usability has beenidentified clearly among the cases depending on their orientation in terms of end-users.Those cases typified as doctor-to-doctor telemedicine services focused on usability to avoidadditional data-entry and reduce clinicians’ workload while doctor-to-patient cases (such asMaccabi and ITHACA) focused on usability in terms of accessibility to patients.

The technology and processes required to provide a continuous and reliable maintenanceand telemedicine service monitoring was present in all the cases. Vendor initiatives hadservice monitoring as a key value proposition. Healthcare providers – with the exception ofITHACA, due to its partnership with an IT company – opted to internalise the servicemonitoring. In all the cases, however, a good collaboration among service monitoring teamsand technology providers was seen as crucial to guarantee the quality of the service.

Clarity in the procurement process and access to expert advice was in all the casesconsidered to be critical so as to face better future developments of the telemedicineservices. A lack of guidelines in pre-commercial procurement was detected particularly inhealthcare providers’ initiatives (i.e., Maccabi and ITHACA).

Finally, an attachment to mature and standard technologies and interoperability wasconsidered by all the cases to be fundamental to scaling-up their solutions.



8. Glossary: Definitions and Abbreviations

This glossary of terminology relevant to the field of technical infrastructure and marketrelations was developed by this special interest group 4 (SIG 4) to accompany thedeliverable.

Concept Provisional definition

ADSL Asymmetric digital subscriber line (ADSL) is a type of digital subscriber line (DSL)technology, a data communications technology that enables faster data transmissionover copper telephone lines than a conventional voice band modem can provide.

CDA Clinical Documentation Architecture. This is a document mark-up standard thatspecifies the structure and semantics of “clinical documents” for the purpose ofexchange between healthcare providers and patients.

DICOM Digital Imaging and Communication in Medicine.

ECG Electrocardiography is a transthoracic (across the thorax or chest) interpretation ofthe electrical activity of the heart over a period of time, as detected by electrodesattached to the surface of the skin and recorded by a device external to the body.

HER Electronic healthcare record.

FTP File transfer protocol.

GPRS General packet radio service. This is a packet-oriented mobile data service on the 2Gand 3G cellular communication system’s global system for mobile communications(GSM).

GSM Global System for Mobile Communications. Originally Groupe Spécial Mobile, GSM isa standard set developed by the European Telecommunications Standards Institute(ETSI) to describe protocols for second generation (2G) digital cellular networks usedby mobile phones.

HL7 Health Level Seven. HL7 is the global authority on standards for interoperability ofhealth information technology.

HTTP Hypertext transfer protocol.

IP The Internet Protocol (IP) is the primary protocol in the Internet Layer of the InternetProtocol Suite. It has the task of delivering packets from the source host to thedestination host solely based on the addresses.

LAN Local Area Network. A local area network interconnects computers in a limited areasuch as a home, a clinic, or a hospital.



Concept Provisional definition

PACS Picture archiving and communication system.

SMS Short message service.

SNOMED Systematized Nomenclature of Medicine.

www World wide web.



9. Bibliography

Bos, L. (2008). Pre-commercial procurement. European Commission: Strategy for ICT research andInnovation Unit. (http://cordis.europa.eu/fp7/ict/pcp/msinitiatives_en.html) (Accessed 2014-09-05)

Chan, C. V., Matthews, L. A., & Kaufman, D. R. (2009). A taxonomy characterizing complexity ofconsumer eHealth literacy. In AMIA Annual Symposium Proceedings (Vol. 2009, p. 86). AmericanMedical Informatics Association. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2815448/(Accessed 2014-09-05)

Christie, C. (2011). Report on the Future Delivery of Public Services by the Commission chaired byCampbell Christie. http://www.scotland.gov.uk/Resource/Doc/352649/0118638.pdf (Accessed 2014-09-05)

Directive 2014/24/EU of the European Parliament and of the Council of 26 February 2014 on publicprocurement and repealing Directive 2004/18/EC http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=uriserv:OJ.L_.2014.094.01.0065.01.ENG (Accessed 2014-09-05)

Edler, J., & Georghiou, L. (2007). Public procurement and innovation—Resurrecting the demand side.Research policy, 36(7), 949-963.http://www.sciencedirect.com/science/article/pii/S0048733307000741 (Accessed 2014-09-05)

Lehoux, P. (2004). Patients' perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies. BMC Health Services Research, 4(1), 28.http://www.biomedcentral.com/1472-6963/4/28 (Accessed 2014-09-05)

http://cordis.europa.eu/fp7/ict/pcp/msinitiatives_en.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2815448/

http://www.scotland.gov.uk/Resource/Doc/352649/0118638.pdf

http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=uriserv:OJ.L_.2014.094.01.0065.01.ENG

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http://www.biomedcentral.com/1472-6963/4/28

Documents

Deliverable D7.2 Report on SIG4 Technical infrastructure